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Males are the most affected group, especially those engaging in competitive sports, but when compared to its counterpart, anorexia, it’s relatively unknown, mainly because how difficult it is to recognize, often being confused with being abnormally keen to physical activity.

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"Male Body Image: The Roles of Sexual Orientation and Body Mass Index Across Five National Studies"

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COPS - Do I have BDD?

This questionnaire has two main uses. First, it can be used as a screening questionnaire to tell whether you might have BDD. Only a trained health professional can make a diagnosis of BDD but the questionnaire can help guide you and your health professional. The questionnaire assumes that you do NOT have a disfigurement or a defect that is easily noticeable or appears only slight to others. The judgment on how noticeable your feature(s) is made by a health professional. The questionnaire can also be used as a measure of severity of your symptoms so you can use it before and after any treatment and provide feedback on whether your symptoms have improved or not. The questionnaire comprises of just 9 items. The range is 0-72 where 72 is the most severe.
Back to Questionnaires

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COPS - Do I have BDD? This questionnaire has two main uses. First, it can be used as a screening questionnaire to tell whether you might have BDD. Only a trained health professional can make a diagnosis of BDD but the questionnaire can help guide you and your health professional.

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Like with many mental disorders, the treatment is mainly psychological and therefore not at all easy. No specific protocols have been validated yet, but family based and cognitive behavioural therapy (CBT) have had the best results. Selective serotonin reuptake inhibitors may be also prescribed as pharmacotherapy.

Structured and empathic counseling helps people to learn to view their bodies in an accepting, appreciative, nonjudgmental way and gain control over constant body checking. Many benefit from practicing relaxation techniques such as mindfulness meditation and many other complementary approaches.

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SYMPTOMS

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The constant preoccupation with perceived smallness interferes with school and career accomplishments. It robs friendships and romantic relationships of spontaneity and enjoyment. Since the person is exceedingly self-conscious at all times, s/he cannot relax and enjoy life without worrying about how other people may be seeing, and criticizing, the perceived smallness.

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There's a saying in bodybuilding culture: "The day you started lifting is the day you became forever small." It's often said lightheartedly, but there's a grain of truth within it. Although it originates from a tongue-in-cheek YouTube video from 2013, I heard it from person after person I spoke to who had, at one point or another, battled muscle dysmorphia.

Every morning, Julius Butcher looked in the mirror, his mind running in circles between satisfaction and horror. Though people - some he didn't even know - would go out of their way to tell him he was muscular and strong, it was hard for him to see himself as having achieved as much as he wanted to. "I often find it so interesting how people view me. I'd like to try it from their perspective if it was possible," he told me. "As humans I believe it's part of our nature to implicitly lessen the value of what we already have and strive for more."

For 29-year-old Nathaniel Shaw it was the same. Having started going to his school's gym to become bigger, eventually he realised he was the only one of his contemporaries still going. Then he was working out twice a day, eating until he threw up, unable to do things because to act was to burn the calories he needed to bulk up, obsessed with looking in the mirror. "I hated the way my body looked. It made me feel suicidal," he said. "I just didn't want to be here. It's hard to explain. It was disgust at myself."

Muscle dysmorphia - or, as it's sometimes known, "bigorexia" - is a form of body dysmorphic disorder in which people, often very muscular men and women, become obsessed with their muscle mass or body fat, usually to the point of it inhibiting their ability to function as a member of society. It can manifest in many different ways: excessive gym attendance; refusing to eat meals you didn't prepare yourself; avoiding social functions to go to the gym; refusing to leave the house for fear that activities will burn calories you need for bulking. It also impairs social and occupational functioning. "MD is characterised by body shame and embarrassment. Many report feeling elevated levels of anxiety and refuse to be seen without clothing in places such as a beach or public swimming pool," explained psychologist Dr David Boyda. Muscle dysmorphia can lead to steroid use and it can lead to death in extreme cases. In the age of the spornosexual body, it's an increasingly pressing issue: the Body Dysmorphic Disorder Foundation has estimated that about ten per cent of male gymgoers may have it. The question is: for people who have such a dependence on how they control their muscle mass and build, how are they coping in self-isolation?

When coronavirus began to loom larger over the UK, and before the UK government closed the nation's gyms, people were already suspending their memberships and keeping away from these enclosed spaces which suddenly felt like hotbeds for contracting the virus. But some were not: as people began to stay at home, but before governments imposed lockdown, many were still going for their daily pump. In mid-March, Channel 4 News reporter Symeon Brown put together a package featuring the attendees of a Wolverhampton gym, who were still going in for a workout while the government had yet to give a final statement on whether the nation's gyms should definitively close.

"At the end of the day this is a place of health and fitness. I'm just assuming everyone's taking the correct precautions," said one gym-goer. "It's a virus, everyone's going to get it," said another. "You've just got to take it on the chin."

Needless to say, the social clips went viral. It was Brown who pointed out in the package that, for these people, going was simply such a part of their lives that they couldn't fathom giving it up. It's enough of a pillar for people that more than 21,000 people have signed a petition calling for gyms to immediately be reopened during a deadly pandemic. It was hard enough for those of us who had suspended our memberships under a cloud, and those who depended on exercise for structure and social interactions were so anxious that they were trying to rewrite medical advice to get to the squat rack. If this was how hard people were taking the end of gyms, how were people with muscle dysmorphia dealing with this sudden spanner in the works? Was the absence of the gym a killer or was the fact they now had fewer external factors trying to interrupt their routines actually a blessing in disguise?

'The idea that one day I might walk through a crowded public space and, because of my body, attract revulsion is exciting to me'

When he was a child, Michael Collins used to hold ice in his hands until it melted: a way of testing his body's limits that would manifest in different ways over time. "Through my teens and twenties, I experienced a strong desire to grow as large as I possibly could." He explained to me, in clear detail, that his interest was never to look like an underwear model or a movie star: it was to push his body to the extremities of bodybuilding, even beyond that. "The idea that one day I might walk through a crowded public space and, because of my body, attract disbelief, confusion, and revulsion from average onlookers is exciting to me."

For Collins, the idea that muscle dysmorphia is a byproduct of "people [starting] as nice, normal gym-goers who just want to get fit... and some kind of germ enters their system" is incorrect. For him, and others he knows, the obsession with muscle was as deep-rooted, long-felt and guilt-inducing for him as homosexuality. "Where does a fetish come from? Why am I gay? Mysterious questions and, in some sense, I feel it's not helpful to dig too deep into them," he said before quoting Zizek: "'Enjoy your symptom.'" If something is causing psychological distress and unhappiness, then deal with it, learn how to live with it, but at the end of the day we're all fucked up in our own unique way."

For some of the people I spoke to, however, muscle dysmorphia was something they realise only in retrospect and which began as a product of already going to the gym and exercising. Butcher started at 15, visiting his local youth recreation centre. But what started as a couple of sessions a week became more all-consuming: muscle-building is a long process that, whether done for the right or wrong reasons, requires a lot of discipline in every aspect of your life. For him, he thinks that devotion turned to obsession and muscle dysmorphia. "Everything that surrounds this lifestyle affects how I look and progress," he explained. "The effort at the gym, diet and sleep all factor into the appearance, so it's with you 24/7."

'[Bodybuilding communities] fully accept MD as an outcome of the growth/conditioning process to the point they do not see it as a disorder'

Nathaniel Shaw started going to the gym at his school whenever the teachers left the door unlocked. For him, an unusually small kid in his year, it was a way of getting bigger and stronger to fight back against bullies. "When you're small, you get targeted. My school wasn't a good school. With weights I felt I could get big enough to defend myself." Slowly, the overeating and the lethargy began to creep in. Although his relationship with the gym became unhealthy, it was also where Nathaniel learned what he was suffering from. It was only when he heard someone in the gym mention muscle dysmorphia, and dismiss it, that Nathaniel went away and realised what it was he was suffering from.

In isolation, it's been up and down for Nathaniel. For the first week, he couldn't bring himself to exercise. But, once he started doing some home workouts, "it made me feel a lot more happy". Meanwhile, he's trying to focus on his mental health with regular meditation. "My muscle dysmorphia, especially at a time like this, is a mind thing. So I'm trying to stay in control of my mind and be happy with how far I've come. And still being active - doing some exercise is better than no exercise."

Dismissal of muscle dysmorphia is not uncommon in the bodybuilding community. "MD tends to be most prevalent in bodybuilding communities, but this community fully accepts MD as an outcome of the growth/conditioning process to the point they do not see it as a disorder," explained Dr Boyda. "Within fitness communities, MD is less prevalent."

This denial is clearest when reading responses to previous articles about muscle dysmorphia. Due to the fact the people who suffer from it are usually incredibly muscular but think they're not, stories often focus on just how much work they're putting in at the gym to heighten this dissonance: the weights they're lifting, the calories they're intaking, the restrictions and the sacrifices. The response from the weightlifting community is often the same. Take a look at some of the Reddit comments on an excellent piece in the Guardian last year by Sirin Kale. In the Subreddit r/MensLib, the conversation is full of personal experiences, empathy and engagement. Then you go to the same article shared on r/bodybuilding, where the most common response is commenters calling the story's characters "scrawny".

'I'm happy with my muscle dysmorphia. At least it never turned into a drug or alcohol addiction'

"What else am I going to spend my time on? I enjoy the struggle and discipline," said one commenter. "The dysmorphia comes and goes over the weeks and months." Another rolled their eyes at the portrayal of one of the character's problematic relationship with food: "The dude probably just didn't know how to diet. That's what happens a lot in bodybuilding."

"I'm happy with my muscle dysmorphia. At least it never turned into a drug or alcohol addiction like so many others," said one commenter to a lot of upvotes. "I think working out, eating properly and repeat is a pretty good baseline standard for any human being." This here is one of the biggest issues: the problem that exercise is a fundamentally healthy endeavour, and often the suggestion is that all people who engage with X numbers of hours of exercise, or want to put on Y pounds of muscle, must have real problems with muscle dysmorphia. "If I go home from work every day and sit and read for two hours, I don't think many people would think of that as a problem," said Collins. "If someone's priorities don't make sense to you it doesn't mean they're wrong. I guess the thing to watch for is if they seem like they're acting in self-destructive ways."

This, as the doctors I spoke to also pointed out, is the important thing to discuss: muscle dysmorphia is not necessarily best gauged by the amount of work you're putting in, but rather the way you're putting the work in. Wanting to bulk up? You do you. But when you refuse to leave the house? That's a danger sign. "Unless you're prepping for a contest there's no need to be so strict with your food," said Maik Wiedenbach, a lauded personal trainer in New York. "If someone is so rigid that they have to eat at three - not 3.15, not at 2.50, I have to eat at three - that's an issue."

Six years ago, Wiedenbach's friend Chris shot himself, in the head, in the gym because of his muscle dysmorphia. "If that doesn't wake you up, nothing will, right?" It was at that point that Wiedenbach sat back and began to look at the way some people had come to engage with weightlifting and how it had come to veer from his own approach. "You think: what about this guy, Ritchie? He tells me he likes to stay home so he doesn't burn calories. Then there's Danny, who spends ten grand a month on drugs and doesn't work." Wiedenbach says he's seen, time and time again, people who need the money for enhancements or amphetamines moving into muscle worship escorting, appearing on the arms of older men at the Met. He himself got an email the other day asking for nude Zoom PTs. "Then, all of a sudden, you're like... woah, these guys aren't cool at all. They're really, really sad."

'I would not go to a big gym anytime soon'

He would try to tell these people that he was worried about them, but to no avail. "They say: you don't have what it takes. You're weak. You'll never be a great bodybuilder. And because Ritchie has his cult at the gym who admires him, and his sugar daddy, there's nobody who will challenge him." For him, the inability to process something was wrong was a huge sign that someone had muscle dysmorphia. "Plus, when you talk to them, they are not capable of actually communicating with you. You'll say something and then they'll say, 'But what do you think of my shoulders?' All they bounce back is statements about their physique."

Wiedenbach has not only seen the consequences of muscle dysmorphia first-hand, he's seen the consequences of coronavirus on a fitness regimen first-hand too. He's just recovering from a bout of it himself when we spoke. "At the peak of my illness I was eating 600 calories a day. Because I couldn't get anything down. That causes massive muscle loss," he explained. "If you have muscle dysmorphia, that's obviously going to send you somewhere else." Even declared negative, he's still trying to get his lungs back to full functioning fettle: "You need to spend two weeks just expanding the distance you're walking. And once you've done that you can do little stuff for the extremities, which don't require that much oxygen - biceps, triceps - and then you can slowly work to chest, back, legs." He said he has another five weeks before he can work out at full capacity again, meaning that, between incubation and full health, he'll have taken eight weeks off his normal regimen. While he understands the importance of the gym for people who rely on it as a form of meditation, he still thinks opening them up anytime soon is a suicide mission. "I would not go to a big gym anytime soon. I would invest in some equipment, talk to the super and install it in the basement of our building. But you would not get me to an Equinox. No way."

Often, the people I spoke to mentioned that there were two versions of their self-perception: the self they saw in relation to normal people, where they could register that they were muscly and big, and their perception of themselves when they were at the gym. "Walking in the street, people would say my arms were huge, or kids would point at me and say, 'Look at the muscles on that guy!'" recalled Nathaniel Shaw. "Then you still go to the gym and someone would say your chest is too small, your shoulders are too small. When they'd say things like that, it felt the same as when I first looked in the mirror."

Michael Collins, however, has always relied on community to help him escape the moments when dysmorphia takes hold. "The only days where it feels like my mental image is warped in a dysmorphic sense are really bad mental health days," he said, "and that's when I rely on my fellow gay musclehead friends to talk me back into a healthier state of mind."

'The gym is a kind of third space, neither home nor work, and it offers a lot of the same social benefits that you might expect a faith community to offer'

For Collins, the pandemic has not diminished his closest friends in the bodybuilding and weightlifting community: they still talk in their group chat, keep each other motivated. But, says Collins, the "ambient sense of being part of a larger community is missing... the people seen several times a week over years, people you might have a five-minute conversation with every now and again". People who he just happened to be at the gym with a few times a week would come up and compliment him on his hard work when he was preparing for bodybuilding competitions, and now those smaller encounters, that miasma of general support, is gone. "The gym is a kind of third space, neither home nor work, and it offers a lot of the same social benefits that you might expect a faith community to offer," said Collins. "It is currently in the deep freeze and I don't know what state it'll be in when things finally thaw."

If the closure of gyms is hard enough for everyone, that makes the loss twice as hard for those with dysmorphia. For Dr David Boyda, managing expectations at this time is vital: "Without resistance or weight, one should expect to see a reduction of their muscle mass coupled with some loss in conditioning (fat levels) as individuals become more sedentary." This is especially true, he says, if you're low in equipment - and considering that there's been a rush on dumbbells, this will certainly be some people who are suffering most. He recommended bodyweight exercises classes on YouTube to maintain muscle mass as much as one can and making good use of whatever the current exercise allowance is under government guidelines.

Wiedenbach mentioned that perhaps one of the hardest things for people so focused on their bodies is not being able to get the validation of showing it off at the gym. "There's a difference between choosing isolation and being told you do not have your outlet, the place where you're being admired," he said. "Your marketplace is gone. You can't show off. And if that was all you had? Well, suicides have doubled in New York City." Michael Collins said not having chances to "passively show off", either at the gym or in casual hook-ups, meant validation was light on the ground for him. "The little hit of positive reinforcement from uploading a picture to Instagram or Twitter isn't the same as an in-person encounter."

'The leaner you stay through all this, the better your hormones when you're through all this and you go back to the gym'

While Collins remains happy with the muscle he's building - he gathered a fairly solid home gym together "through a combination of determination and luck" - others have accepted that this might not be the time to bulk. For Butcher, the bigger concern is what this will mean for his diet. "I need calories to maintain my weight," he said. "If a certain kind of food - from beyond our borders - was in low supply I'd of course be forced to change my habits."

With access to heavy weights limited, diets harder to follow and less natural daily exercise to supplement one's fitness regimen, Wiedenbach said that now is the time for people, especially those who place this much importance on their body, to swap priorities. "What I would urge people is: stay lean. Don't worry too much about bulking. The leaner you stay through all this, the better your hormones when you're through all this and you go back to the gym," advised Wiedenbach. "That is something you have to hammer into people and the average musclehead doesn't get. He's gonna be like, 'Oh, fuck, I've lost all this weight, I'm gonna eat.' But the truth is you don't have the equipment to gain that muscle back quickly. Unless you have a really good home gym, which most of us don't." Even Wiedenbach, a man with an exceptional physique and a unique ability to pound on muscle mass - "I'm a genetic outlier" - has appreciated that the most he can use at the moment is a couple of resistance bands to try and maintain.

Butcher said that towards the start of the pandemic in Sweden he found himself out for two weeks with what he is certain was Covid-19. But, rather than panicking about what it might mean for his body, the break from his exercise regime was actually a helpful period of recovery. He also says that, as some doctors also confirmed, time is often the greatest healer of muscle dysmorphia: having worked out the way he has for six years, the darker thoughts are easier to dispel, self-knowledge overcoming self-hatred. "Even though I believe I'll have some degree of muscle dysmorphia for the rest of my life, I do believe I'm way better at noticing my inner monologue now," he said, "and when that depressing voice of 'no gains' pops up I can rest assured it's temporary."

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What it's like to have muscle dysmorphia during lockdown

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There's a saying in bodybuilding culture: "The day you started lifting is the day you became forever small." It's often said lightheartedly, but there's a grain of truth within it. Although it originates from a tongue-in-cheek YouTube video from 2013, I heard it from person after person I spoke to who had, at one point or another, battled muscle dysmorphia.

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Bigorexia, Steroid Use & Psychology of Body Building

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Bigorexia: Never Buff Enough | BBC Newsbeat

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